Healthcare Provider Details

I. General information

NPI: 1720107717
Provider Name (Legal Business Name): MARK BENNETT WAGGONER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 HARVARD CT
PLANO TX
75093-3450
US

IV. Provider business mailing address

3104 HARVARD CT
PLANO TX
75093-3450
US

V. Phone/Fax

Practice location:
  • Phone: 972-333-6204
  • Fax:
Mailing address:
  • Phone: 972-333-6204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13820
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number13820
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: